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Full text of "United States Navy Medical News Letter Vol. 27, No. 8, 20 April 1956"

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NavMed 369 




Editor - Captain L. B. Marshall, MC. USN (RET) 



Vol. 27 Friday, April 20, 1956 No. 8 



TABLE OF CONTENTS 

Voluntary Retirement 2 

Regional Enteritis 3 

Treatment of Cirrhosis of the Liver 4 

Discoid Lupus Erythematosus 6 

Treatment of Amebiasis by Glaucarubin 8 

Joint and Bone Disease Due to Mycotic Infection 9 

Acute Urinary Retention Due to Drugs 11 

Therapy of Carcinoma of the Urinary Bladder 13 

Operative Treatment of Pectus Excavatum 15 

Reunion at National Naval Medical Center 17 

Residency Training in Allergy 17 

Penicillin Prophylaxis of Gonorrhea 17 

"The United States Navy" 18 

From the Note Book 19 

Board Certifications 21 

Recent Research Reports 22 

Staffing Report (BuMed Inst. 6320. 16A) 23 

Antibiotics, Extension of Potency Dates (BuMed Notice 6710) 23 

Defective Medical and Dental Material (BuMed Inst. 6710.28) 24 

DENTAL SECTION 

Inspector General in Near East. .. 24 Prosthodontic s, Periodontology 26 

Visit to NTC, Bainbridge 24 Dental Division, AADS . . 26 

"Mr. Disaster" on TV 25 Training, Fiscal Year 1957 26 

Postgraduate Course Selections , . 25 Training after 1 July 1956 .... 27 



Interns Selected for Fiscal Year 1957.. 27 
MEDICAL RESERVE SECTION 

Research Clerkship Training 28 Training in Submarine Medicine 29 

AVIATION MEDICINE SECTION 

Accidents and Incidents 30 Student Flight Surgeons to Solo . 34 

Hyperventilation Syndrome 33 Air Travel & Ambulatory Patient 36 

Discrepancies in SF 88 's. . . 39 



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Medical News Letter, Vol. 27, No. 8 



Policy 

The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up -to date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be nor 
are they susceptible to use by any officer as a substitute for any item or 
article in its original form. All readers of the News Letter are urged to 
obtain the original of those items of particular interest to the individual. 

****** 
Notice 

Due to the critical shortage of medical officers, the Chief, Bureau 
of Medicine and Surgery, has recommended, and the Chief of Naval Person- 
nel has concurred, that Reserve Medical officers now on active duty who 
desire to submit requests for extension of active duty at their present sta- 
tions for a period of three months or more will be given favorable consid- 
eration. BuPers Instruction 1926. IB applies. 

Voluntary Retireme nt 

The policy of the Bureau of Medicine and Surgery is to recommend 
approval on requests for voluntary retirement of medical officers who have 
20 or more years' active service creditable for retirement. However, be- 
cause of personnel shortages, the Bureau may of necessity have to recom- 
mend modification of the requested effective date because it may not always 
be possible to furnish a qualified relief by the time specified in the request 
(PersDiv, BuMed) 

****** 

Change of Addres s 

Please forward requests for change of address for the News Letter to 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addres ses . 



Medical News Letter, Vol, 27, No. 8 



3 



Regional Enteritis 

Regional enteritis, an inflammatory disease primarily involving the 
distal part of the small intestine, presents many interesting facets. It is 
not a common disease and is often difficult to diagnose. In addition, its 
course may be quite variable and it may present many complications, locally 
as well as systemically. Its cause is not known. Its response to treatment 
is variable. Treatment in itself may vary because patients with this disease 
may be subjected to medical management, surgical management, or x-ray 
therapy. 

The primary pathologic process seems to be an obstructive lymph- 
edema involving the lymphatics of the submucosa. Consequent on this, there 
develop interstitial edema and thickening, fibrosis, and eventual ulceration 
and inflammation of the lining of the small intestine as well as marked hyper- 
trophy and inflammation of the bowel wall. Most pathologists who have studied 
this disease have been impressed by the presence of tubercles which are non- 
caseating and which may occur in any layer of the bowel wall, but are noted 
most often in the muscularis. 

This disease may be considered as exhibiting phases that can be 
described as acute enteritis, ulcerative enteritis, and hyperplastic enteritis. 
Early in the course of the dieease, when it is in the stage of acute enteritis, 
the patient may have abdominal pain^ nausea, perhaps vomiting, and mild 
diarrhea. Pain may be present in the right lower quadrant of the abdomen. 
It may be associated with tenderness to palpation and with muscle spasm in 
this region.; There maybe low-grade fever. Laboratory studies frequently 
disclose leukocytosis. This phase of the disease may be short and may sub- 
side completely. 

In many instances, however, the disease progresses to the phase of 
ulcerative enteritis, and eventually hyperplastic enteritis. When ulcerative 
enteritis has occurred, there is usually a history of diarrhea which may be 
mild to severe. Abdominal pain and cramping are usually present. In ad- 
dition, there is loss of weight, weakness is complained of, and the patient 
usually has a very poor appetite. The diarrhea, when moderate or severe, 
may occur during the night as well as during the day. Approximately 15% 
of these patients are said to exhibit blood in the stool during the diarrheal 
phase, but massive bleeding is rare. On examination, patients in this phase 
of the disease may present an appearance consistent with that of anemia of 
varying degrees of severity. In addition, abdominal tenderness is frequently 
present and a mass is often felt in the right lower quadrant of the abdomen. 
If loss of weight has been severe and anorexia marked, there may be evidence 
of peripheral edema. In this phase of the disease, one may see evidence of 
complications which may occur locally and may consist of fistulas within the 
abdomen or fistulas from the ileum or other parts of the small intestine to 
the abdominal wall. In addition, peripheral complications may develop, 
such as iritis, arthritis and pyoderma gang raeno sum. 



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Medical News Letter, Vol. 27, No. 8 



When the disease has persisted long enough and attempts at repair 
have been made, the phase of hyperplastic enteritis is entered. It may not 
always be simple to divide the disease into these stages as outlined, but it 
is believed that this approach to the problem serves to clarify the thinking 
on the subject. When the bowel wall is thickened by the hyperplastic phase 
of regional enteritis, the commonest clinical picture is that of intermittent 
incomplete obstruction of the small intestine. The patient may complain of 
rhythmic cramping. There may be associated nausea, vomiting, and disten- 
tion with borborygmi easily audible, and visible peristalsis may be easily 
seen. In addition, one may palpate a mass if the abdomen is not too distended. 
Occasionally, when the involved ileal segment lies low in the pelvis, it forms 
a mass that may be felt bimanually as an extrarectal mass. Usually, there 
is constipation, though diarrhea maybe present. As might be expected, the 
patient has become increasingly debilitated from his disease by this time. 

Three general methods of treatment are currently employed in the 
management of regional enteritis : surgical, medical, or a combination of 
x-ray and medical. 

One may consider the indications for surgical management to exist 
when any of the conditions which follow are encountered: (1) obstructive 
disease, (2) extensive stenosing lesion with nutritional deficiency failing to 
respond to medical treatment, (3) presence of fistulas which may be ileoileal, 
ileojejunal, ileocolic, ileovesical or enterocutaneous, (4) abscess formation 
and sepsis, and (5) perforation with peritonitis. 

The following situations might be considered as indications for med- 
ical treatment: (1) localized segmental involvement without complications; 
this will include most patients with regional enteritis; (2) long-standing low- 
grade disease process with no progression; (3) recurrence after surgical 
treatment; (4) extensive involvement, with multiple skip areas; and (5) to 
allow the acute phase to subside. 

From the discussion, it is obvious that no single therapeutic regimen 
may be applied to all patients with regional enteritis. The treatment prog- 
ram to be followed is dictated by the clinical condition of the patient at the 
time he is observed and by the phase of the disease manifested at that time, 
(Sauer, W. G. , Regional Enteritis: Diagnosis and Medical Management: 
Postgrad. Med., 19^: 216-220, March 1956) 

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Treatment of Cirrhosis of the Liver 

Cirrhosis of the liver represents a chronic disease caused by serious 
parenchymal damage to the liver, usually of long -continued or repetitive type, 
in which malnutrition is usually regarded as an important accompanying and 
predisposing etiological factor. Because of its vital and widely diversified 



Medical News Letter, Vol. 27, No. 8 



5 



metabolic functions, the liver is commonly exposed to a variety of damaging 
agents in the form of toxic chemicals, infections, circulatory disturbances, 
and systemic metabolic abnormalities, but the nutritional state of the organ- 
ism is believed to act as a basic underlying factor which is capable of con- 
ditioning susceptibility or resistance to cellular injury. 

Many classifications of hepatic cirrhosis have been proposed in the 
past, most of which are acceptable for general clinical orientation. The 
major forms which constitute quantitatively the most important therapeutic 
problems in the United States are: (1) Laennec's, or portal, cirrhosis, 
(2) postnecrotic cirrhosis, and (3) biliary or obstructive cirrhosis. Much 
rarer in incidence in this country are (4) parasitic cirrhosis, (5) pigmentary 
cirrhosis, and (6) hepatolenticular degeneration; (7) cardiac or congestive ■ 
cirrhosis and (8) syphilitic cirrhosis are special forms which depend upon 
the presence of coexisting disease, and the management of these depends to 
a large extent upon successful treatment of the underlying conditions. Special 
mention should be made in passing of the tropical form of malignant malnutri- 
tion known as kwashiorkor which is indigenous to certain areas of Africa. It 
is characterized by serious and even fatal liver damage with cirrhosis and 
is due to the use of poor diets which are strikingly deficient in protein of 
high nutritional value. In many ways, certain basic principles underlie the 
therapeutic approach to all types of liver-cell injury. This summary deals 
primarily with the commonest of these diseases, portal or Laennec 's cirrhosis, 
Laennec's cirrhosis in the past has often been designated as "alcoholic 
cirrhosis" because of the frequent, but by no means invariable, association 
of the disease with chronic alcoholism. During the past 18 years, a multi- 
disciplinary attack on the problems of hepatic metabolism has resulted in 
an accumulation of impressive evidence, both experimental and clinical, 
which in general relegates alcohol to a secondary position as an etiological 
factor, subordinate to malnutrition, especially in regard to good quality of 
protein and a number of vitamins and related nutrients. There remains, 
however, some evidence and opinion to suggest that the toxic action of ethyl 
alcohol may be important in the production of liver damage. From the prac- 
tical standpoint at present, therefore, in addition to the prohibition of alco- 
holic beverages, the major therapeutic effort is directed toward the 
reestablishment of an optimal state of nutrition, 

A specific plan of therapy of cirrhosis involves bed rest, the pro- 
hibition of alcoholic beverages, the providing of an attractively prepared 
nutritious diet, the sharp limitation of dietary sodium intake, the adminis- 
tration of antibiotics as needed to control intercurrent infection, the per- 
formance of paracentesis for control of marked ascites, and the use of 
mercurial diuretics as a supplement to other measures in the control of 
fluid and sodium retention. Special measures are needed to meet complica- 
tions and emergency situations as they arise. 



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Medical News Letter, Vol. 27, No. 8 



The successful therapeutic management of cirrhosis of the liver is 
best handled as a team project involving the internist, the dietition, and the 
nursing staff, with occasional need for active surgical cooperation. In a 
chronic disease of this sort with a spontaneously variable course, it is often 
difficult to assess the precise value of various measures. Enormous patience 
is required on the part of the entire attending staff because satisfactory food 
intake, the most important single item in the plan of management, will often 
be disappointing for long periods and cooperation by the patient may be very 
poor. Plans must be made for the treatment to be as chronic as the disease, 
and a long period of hospitalization may serve not only as a turning point in 
a previously downward course, but also as a period of reeducation into a 
new pattern of living during which proper food habits may be well established 
and the first stages in reducing or eliminating alcoholic intake can be attemp- 
ted. Rehabilitation of cirrhotic patients, therefore, extends far beyond the 
actual dietary details and remedial medications employed. For the pathway 
back to health for these persons is along, rough, and discouraging one, espec- 
ially when alcoholism is a major etiological factor, and necessarily involves 
the acceptance of a diet which is of low palatability for many persons when 
combined with abstinence from alcohol. For these reasons, an attitude of 
patience and sympathetic understanding on the part of the physician and his 
associates is important enough to justify special comment. (Gordon, E. S. , 
The Treatment of Cirrhosis of the Liver; Arch. Int. Med., 97: 340-349, 
March 1956) v 

Discoid Lupus Erythematosus 

Although it is generally accepted that the various forms of lupus ery- 
thematosus are merely different manifestations of the same disease, the 
most common variety, namely, the chronic discoid form, has been regarded 
as primarily a localized manifestation whose systemic changes are either 
absent or missed. The object of this study is to point out that these general- 
ized changes are very common in discoid lupus and have hitherto been over- 
looked. 

Chronic discoid lupus is characterized by skin lesions which in the 
active phase consist of erythematous plaques of varying sizes with scaling, 
follicular plugging, followed in the healing stages by atrophy and either 
depigmentation or hyperpigmentation. 

To the best of the authors' knowledge, no one has gathered a group of 
patients with chronic discoid lupus and carefully interviewed them, utilizing 
a questionnaire with particular emphasis on the clinical course of their illness 
and the systemic changes which they might have noted during it. This method 
was used by the authors. Each patient had, in addition, a complete physical 



Medical News Letter, Vol. 27, No. 8 



7 



examination at the same time. The patients described were attending 
dermatology clinics and had had a diagnosis of chriDnic discoid lupus made 
by competent dermatologists either by the clinical appearance or by biopsy 
of the lesion or both. Patients with discoid-type lesions and compatible 
biopsies who had obvious disseminated disease, with fever, severe arthritis, 
anemia, and other changes typical of acute disseminated lupus concurrent 
with the onset of their cutaneous lesions, were not included in this series. 
Forty-one patients were selected as outlined. Twenty-six had the localized 
discoid form and fifteen had the generalized discoid form. Routine labora- 
tory work, liver function tests, heparinized L. E. cell preparations, skin 
biopsies, and electrocardiograms were obtained on most of the patients. 

The detailed clinical features are presented in tables where their in- 
cidences are compared to those found in a series of 6Z cases with systemic 
lupus erythematosus studied at this hospital several years ago, or in other 
similar series. The sex ratio was 71% female in the discoid group as com- 
pared to 89% in patients with systemic disease. The median age of onset 
is 32 years in the discoid group versus 24 years with systemic disease. The 
disease appeared in both the localized and the generalized discoid group at 
about the same ages. Complete spontaneous remission in the skin lesions 
occurred in four patients only, although remissions in their systemic com- 
plaints were very frequent. The spontaneous over all remission rate in 
systemic lupus erythematosus is about 40%. 

Chronic discoid lupus erythematosus has been regarded as primarily 
a skin disease with rare systemic manifestations. In order to determine 
the truth of this statement, the authors performed a complete history, phys- 
ical examination, and routine laboratory work on a series of 41 patients with 
chronic discoid lupus erythematosus. The patients were divided into two 
groups: the localized discoid form with skin lesions above the chin, and the 
generalized discoid form with cutaneous involvement on the face and else- 
where. Sixteen of the 26 patients (62%) of the localized discoid group had 
evidence at some time in the course of their illness of arthritis, fever, 
Raynaud's phenomenon, pleurisy, or other systemic changes by history and 
physical examination alone. Fourteen of the 15 cases of generalized discoid 
disease had such changes. If, in addition, laboratory abnormalities such as 
leukopenia, elevated sedimentation rate, hyperglobulinemia, or abnormal 
flocculation tests were considered, then 24 of the 26 with localized discoid 
disease and all of the 15 in the generalized discoid group showed such changes. 
Therefore, there was evidence of systemic involvement in 96% of this group 
of patients with chronic discoid lupus. 

Three different modes of onset of discoid lupus were found. Thirty- 
three patients (72%) had cutaneous changes initially, followed in 45% of the 
group by rheumatoid-like arthritis. Seven patients had rheumatoid arthritis 
prior to the appearance of discoid lesions. One patient had a biologic false- 
positive serologic test prior to skin lesions. 



• 



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Medical News Letter, Vol. 27, No. 8 



The classification of lupus erythematosus is an arbitrary one. There 
are many transitions between the types. Discoid lupus, from its inception, 
is a systemic disorder which is a variant of the more malignant acute dis- 
seminated form. The "benign" -appearing cutaneous lesion may be a herald 
of advanced systemic manifestations which may be present at the same time 
or later when the skin changes have healed. Therefore, all these patients 
should have a thorough general medical survey. The form of therapy in- 
stituted depends entirely upon the extent of the disease. (Dubois, E. L. , 
Martel, S. , Discoid Lupus Erythematosus: An Analysis of Its Systemic 
Manifestations; Ann. Int. Med., 44:482-495, March 1956) 

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Treatment of Amebiasis by Gla ucarubin 

Compounds possessing potent amebacidal properties in experimental 
amebiasis have recently been isolated from plants of the genus simarouba, 
in particular from Simarouba amara and S. glauca. One of these fractions, 
a crystalline glycoside, has been designated glaucarubin. The present article 
reports an evaluation of this product in the treatment of acute and chronic 
amebiasis in man. 

The drug was administered to 87 patients with amebiasis. The labora- 
tory diagnosis of amebiasis was made in the chronic cases (78 patients) by 
examining several fecal samples obtained shortly after administration of a 
saline laxative. In the acute cases (9 patients), the fecal samples were exam- 
ined immediately after discharge. 

The drug was administered orally, dividing the daily dose into three 
parts. The dosages employed were varied considerably due to using a new 
drug and trying to establish an adequate therapeutic dosage. A schedule of 
3mg. /kg. /day for five days was finally developed. 

At the start of the treatment, all of the patients with chronic amebiasis 
had great quantities of cystic forms of E. histolytica in the feces. No patient 
could be considered a simple asymptomatic carrier because all had in variable 
degrees signs and symptoms of chronic amebiasis. When these patients were 
subjected to treatment with glaucarubin, clinical improvement was evident 
in all from the third to the fourth day, including those patients in whom the 
parasite continued to appear in the feces. Symptomatic improvement per- 
sisted after discontinuance of therapy and those patients who were infected 
only with E. histolytica were completely free of signs. 

When treatment was started in the acute cases, all had the symptoms 
and signs characteristic of the severe form of amebic dysentery and con- 
tained a great number of mobile E. histolytica trophozoites in the feces. In 
these patients, the clinical response to treatment was rapid and spectacular. 
After 24 hours of treatment, the frequency of the stools had diminished 



Medical News Letter, Vol. 27, No. 8 



9 



greatly, as well as the intensity of the tenesmus and abdominal pain. Be- 
tween the second and the fourth day, mucus and blood disappeared completely 
from the feces and they were of normal appearance. 

Clinical improvement was evident from the first to the sixth day after 
treatment had begun. No toxic symptoms were noted and the drug was well 
tolerated. Parasitologic examinations of the stool gave negative results 
as early as the first day of treatment; in only two patients did the parasites 
persist. No changes were detectable in blood counts and differentials in 
36 patients or in liver function tests which were performed on 10 patients 
before and after treatment. After treatment was terminated, 54 patients 
were observed for a period of 1 to 13 months. Eight of the patients with 
chronic amebiasis developed recurrence of E. histolytica. (Del Pozo.E.C. , 
Alcaraz, M. , Clinical Trial of Glaucarubin in Treatment of Amebiasis: 
Am. J. Med. , XXj 412-417, March 1956) 

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Joint and Bone Disease Due to Mycotic Infection 

The importance of pathogenic fungi as a cause of bone and joint disease 
has taken on added significance as the result of several developments. First, 
the control of pathogenic bacteria with chemotherapeutic and antibiotic agents 
has increased the relative frequency. Second, increased travel incident to 
military service and other factors has resulted in a dissemination of fungus 
infections. Third, therapeutic agents of a more effective nature for several 
of the mycotic organisms have become available recently. 

Twenty-five cases of fungus disease, observed at the McGuire Veterans 
Hospital and the Hospital Division of the Medical College of Virginia, have 
been reviewed. These included 11 cases of blastomycosis , 4 of coccidioido- 
domycosis, 4 of cryptococcosis, 3 of actinomycosis, 2 of histoplasmosis, 
and 1 of nocardiosis. In 8 cases, there was involvement of bone or joint. 

The incidence of mycotic infection is much larger than is generally 
appreciated. The types of infection encountered are about as anticipated for 
this area, with the possible exception of the 4 cases of coccicioidomycosis. 
Each of these, however, gave a history of having traveled or maintained 
a residence in one of the endemic areas of California. The age range varied 
between 18 and 59 years, and was not felt to be unusual. The group of 25 
included only one female patient. 

Pathogenic fungi must be considered in the differential diagnosis of 
all infections involving bones and joints. Although, neither clinical studies 
nor roentgenographic examination can make an absolute distinction between 
a mycotic and a bacterial infection, there are certain distinguishing features 
that will aid in the differentiation. Mycotic joint and bone disease occurs as 
a part of a systemic infection. Dissemination or spread is by means of the 



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Medical News Letter, Vol. 27, No. 8 



bloodstream with the possible exception of actinomycosis, in which case 
direct extension occurs. The lesions are usually multiple, widespread, and, 
in general, show a predilection for cancellous rather than tubular bone. In 
the case of cryptococcosis, there is a tendency towards involvement of the 
bony prominences. The roentgenographic appearance is that of an almost 
pure osteolytic process with little bone or periosteal reaction except, again, 
in occasional cases of actinomycosis. Sequestrae, if present, are usually 
small — a contrast with the usual reaction resulting from bacterial infection. 
When joints are involved, it is usually by direct extension from the initial 
bone lesion, and extensive damage occurs to the bone, cartilage, and the 
synovial membrane. Roentgen evidence of bone damage may exist for many 
months after skeletal pain and signs of systemic infection have disappeared. 
Tuberculous bone and joint lesions are most apt to be confused with mycotic 
infections, and it maybe almost impossible to differentiate the two. Solely 
from a roentgenographic standpoint, mycotic infection of the bone maybe 
difficult to distinguish from multiple myeloma, certain cases of metastatic 
carcinoma, eosinophilic granuloma, and other conditions. The clinical 
features of these varying diseases, however, should not offer real difficulty. 

The failure to respond to the usual antibiotic and chemotherapeutic 
agents should arouse suspicion that the infection is not one resulting from 
the usual pathogenic bacteria. The diagnosis, however, can only be made by 
recovering the organism from the joint, bone, abscess cavity, sinus tract, 
skin, sputum, urine, or spinal fliiid. 

The prognosis for certain of this group of diseases has improved, due 
to the introduction of the aromatic diamidines as a more effective treatment 
measure. Stilbamidine is unstable in solution and has been found to be toxic 
for the trigeminal nerve; however, 2-hydroxy-stilbamidine does not have 
these disadvantages and is equally effective. Blastomycosis, cryptococcosis 
(except of the central nervous system) and actinomycosis have proven to be 
the most effectively treated. The various sulfonamides and antibiotics have 
been effective in some cases of actinomycosis and nocardiosis. Iodides in 
various forms and quantities have formerly been the drugs used most exten- 
sively and for the longest period of time. This drug has been effective to a 
limited degree -in the treatment of blastomycosis, cryptococcosis, actino- 
mycosis, and nocardiosis. Otherwise, the management has been largely 
symptomatic, supportive, or with the use of a wide variety of drugs and 
other treatment measures that enjoyed brief and unwarranted periods of 
popularity. To date, no treatment of value is available for coccidioidomy- 
cosis, histoplasmosis, or central nervous system cryptococcosis.( Toone, E. C. 
Jr. , Kelly, J. , Joint and Bone Disease Due to Mycotic Infection: Am. Med. 
Sci. , 231:263-272, March 1956) 



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Medical News Letter, Vol. 27, No. 8 



11 



Acute Urinary Retention Due to Drugs 

Of the various drugs known to influence micturition in man, some are 
capable of producing urinary retention by interfering with the bladder empty- 
ing mechanism, A number of these are in wide clinical use today. For the 
most part, these medications affect bladder muscle function either by alter- 
ing bladder muscle action or by causing profuse diuresis and consequent 
over distention of the bladder. In both instances, predisposing factors are 
important, and, in the experience of the authors, the most significant of 
these are debility, recumbency, and prostatism. The problem of acute uri- 
nary retention following the use of drugs occurs chiefly in middle aged and 
elderly men, but has been observed at times in young vigorous men as well 
as women. 

The practicing physician needs to be familiar with the potential bladder 
effect of medications which he administers or prescribes, and must assess 
the bladder status of his patient prior to administration of any one of the drugs 
known to be capable of interfering with the bladder emptying mechanism. 

Because the relation of parenterally administered mercurial diuretics 
to acute urinary retention has been considered in a previous article, concern 
in this presentation is limited to other drugs. 

The physiology of micturition is not very clear. Its components are 
complex. Normal detrusor action by cholinergic stimulation results in 
reciprocal bladder wall contraction and vesical neck relaxation. Anticho- 
linergic effect on the bladder is associated with relaxation of the bladder 
wall and vesical neck constriction. The explanation for this reciprocal action 
between the detrusor muscle and vesical bladder neck is unknown. 

The most interesting development in the field of anticholinergic drugs 
in recent years has been the synthesis of new quarternary ammonium com- 
pounds which, in therapeutic doses, block parasympathetic ganglia and 
effector sites. In much larger doses, they also block sympathetic ganglia 
and neuromuscular end plates. Methantheline (banthine) bromide was the 
first of these in clinical use. Its effect in the treatment of gastrointestinal 
disorders, chiefly peptic ulcer, depends upon its action in decreasing secre- 
tions and motility. It has also been advocated in ureteral and vesical spasm, 
hyperhidrosis, and for the control of salivation. 

Ephedrine and congeners intensify the normal adrenergic innervation 
of the blr.dder, believed to oppose cholinergic innervation, and, therefore, 
have an effect on bladder function similar to that of anticholinergic drugs. 

Other drugs in this category are: amphetamine {benzedrine) sulfate, 
phenylephrine (neosynephrine) hydrochloride, naphazoline (privine) hydro- 
chloride, mephenetermine (wyamine) sulfate, methamphetamine {methedrine) 
hydrochloride, et cetera. 

Ganglion blocking drugs have recently come into medical use for the 
treatment of hypertension. Perhaps the best known among these drugs are 



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Medical News Letter, Vol. 27, No. 8 



hexamethonium and pentolinium tartrate (ansolysen). Both block sympathetic 
and parasympathetic ganglia. Among the many side effects of hexamethonium, 
acute urinary retention has been reported. 

Apresoline, likewise widely used in the therapy of hypertension, has 
been reported to be responsible for difficulty in voiding with hypotonia of the 
bladder. The mechanism of this phenomenon is not clear. 

Antihistaminic drugs have also been incriminated in the causation of 
acute urinary retention. Wolfs on reported an instance following ingestion of 
tripelennamine (pyribenzamine) hydrochloride. Uhle and Knoch mentioned 
several cases of difficult urination and one case of acute urinary retention 
following administration of phenindamine (thephorin) tartrate. 

The antihistamines, among other pharmacologic effects, are known to 
have anticholinergic and adrenergic actions. The mechanism by which these 
agents produce bladder symptoms is believed to be an anticholinergic effect 
of detrusor weakness and sphincter spasticity. 

Van Duzen has also listed the following antihistaminic drugs as pro- 
vocative of bladder symptoms: chlorprophenpyridamine (chlor-trimeton) 
maleate, methapyrilene (histadyl) hydrochloride, thonzylamine (anahist) 
hydrochloride and chlorcyclizine (perazil). 

There is little doubt that morphine and other narcotic drugs are impor- 
tant contributing factors in the production of acute urinary retention, espec- 
ially in debility, recumbency, and prostatism. 

Sulfadiazine ingestion has produced acute urinary retention by deposi- 
tion of crystals in the urethra at the external meatus. 

In the opinion of the authors, no patient with symptoms of prostatism 
should receive anticholinergic, adrenergic, ganglion blocking, antihista- 
minic drugs or opiates unless the need is compelling. Under these circum- 
stances, the smallest doses feasible should be prescribed, and the medication 
discontinued at the earliest possible moment. During administration of such 
drugs, great vigilance should be exercised with regard to bladder status. 
Symptoms of increased urinary frequency, nocturia, slowing of urinary 
stream, and other bladder symptoms may not be volunteered by the patient. 
The physician often can disclose their presence only by specific inquiry. 
More definitive information in regard to bladder status can be obtained by 
determining the volume of residual urine. To disregard such symptoms and 
continue with the use of a drug in any of the above categories may result in 
acute urinary retention. 

As soon as bladder symptoms appear, the offending drug should be 
discontinued. Usually, in the absence of prostatism, this will suffice for 
the return of bladder ftinction to normal, but occasionally catheterization 
will be necessary. When acute urinary retention is precipitated by a drug 
in a man with antecedent prostatic symptoms, conservative measures may 
not suffice. Often, surgery becomes necessary. (Schneierson, S. J. , Bergman, 
H. , Acute Urinary Retention Due to Drugs: J. Urol. , 75:342-346, February '56) 



Medical News Letter, Vol. 27, No. 8 
Therapy of Carcinoma of the Urinary Bladder 



13 



This discussion is based on the study of 103 consecutive cases of car- 
cinoma of the urinary bladder treated by the radiological department in 
cooperation with the department of urology. The authors are satisfied that 
radiation therapy is the method of choice,- at least at the present time, and 
this can be either alone or in conjunction with simple surgical procedures. 
The authors aimed to establish this premise as a fact and to present what 
they have found to be an expedient and successful plan of procedure in the 
therapy of carcinoma of the urinary bladder. 

Most authors agree upon the comparatively simple classification 
which divides bladder carcinoma into two main headings: (1) papillary type, 
and (2) non -papillary, or infiltrating type; each is further defined according 
to cellular type and graded according to activity. 

The papillary type will include those formerly benign papillomas which 
have undergone malignant changes and are the cause of so many errors of 
judgment on the part of the cystoscopist who may decide the fate of the patient 
by the gross appearance of the lesion. The non-papillary type may be either 
ulcerative or nodular in character. 

In either type, one cannot estimate the degree of malignancy, the extent 
of infiltration, or the presence of rnetastases on the gross appearance of the 
lesion alone; furthermore, as Cade points out, it is more disheartening to 
know that the microscopic findings can be misleading as well This is due 
to the fact that small biopsies can completely miss malignant portions of a 
papillomatous tumor and show only the innocent appearance of benign villous 
epithelium, for such tumors are characteristically a mixture of widely dis- 
persed clumps of malignant cells in a large field of benign tissue. Thus, to 
establish a diagnosis requires the exercising of the maximum of good judg- 
ment and scientific investigation. Once a diagnosis has been established, 
there remains a choice of treatment. At present, treatment is limited to 
three choices: (1) surgical excision or fulguration, (2) radiation therapy, 
and (3) the questionable adjunctive treatment with hormones. 

The surgical procedures include transurethral resections, suprapubic 
resections, partial cystectomy, and total cystectomy with transplantation of 
the ureters. The published results of the various procedures belie the con- 
clusion that one method has anything but technical advantages or disadvan- 
tages over the others. 

Radiation treatment includes: (1) roentgen therapy, either of the 
closed external type or the contact type, through a suprapubic wound into a 
mar supialized bladder; (2) radium therapy, either with needles implanted 
into the tumor or with a plaque or a bomb placed within the bladder; (3) the 
implantation of radon seeds into the tumor or its site. Of these choices, 
it can be said that all of them have been tried separately and in combination. 



14 



Medical News Letter, Vol. 27, No. 8 



In plannipig the course of action, the correct diagnosis is of primary 
importance. Then one must consider the extension of the disease. It has 
already been pointed out that there is great difficulty in estimating the extent 
of any lesion. The authors believe that, whenever the diagnosis of carcinoma 
of the urinary bladder is made, the patient should receive the benefits of 
radiation therapy whether or not there is evidence of local extension. 

Another important consideration should be the general condition of the 
patient. Most frequently this is underestimated. The usual conception is 
that, if the general condition of the patient contraindicates surgery, radiation 
therapy is indicated. But with the exception of specific contraindications as, 
for example, cardiovascular disease, the biological effect of ionizing radia- 
tion makes it impossible for such patients to support a treatment of the 
magnitude of an adequate radiation therapy. 

Because of the marked reaction of the bladder to radical radiation 
therapy, two factors pertaining to the patient's general condition must be 
attended before therapy is instituted. First, there must be satisfactory 
drainage of the urinary bladder. If there is an obstructing prostate gland, or 
the tumor mass itself blocks the urinary flow, the surgeon is obligated to re- 
sect and establish adequate drainage. Second, any bladder infection which 
might be present should be combated vigorously. One factor afforded by 
radiation therapy, which is closely related to the general condition of the 
patient, is the excellent psychological effect of being treated as an out-patient 
without having to endure a long hospital stay and formidable surgical proce- 
dures. Lastly, one has to consider previous therapy. Here, the utmost 
understanding between the surgeon and radiotherapist is necessary. If it is 
determined that surgery is indicated, the surgeon should consider the pro- 
cedure from the standpoint of the radiation therapy to follow, remembering 
that maximum tolerated doses must be given if the patient is to be benefited. 
F resh surgical incisions certainly hamper attainment of this goal. 

The authors arrived at their conclusions partly by interpretation of 
the reports of the past, and partly by the results of following what they 
believe to be a systematic procedure for treating cancer of the urinary 
bladder. Their series of cases is not similar to many others reported in the 
literature in that it includes all types of primary carcinoma of the bladder in 
various stages of malignancy. No differentiation is made as to age, sex, or 
general condition of the patient. The ages range from 26 to 87 years with an 
average of 60 years; of these, 73% were males. 

A single course of radiation therapy was given to 81 patients; 15 re- 
quired two courses; and 7 were given three courses. One patient, who had 
received three courses of therapy, later developed a new lesion on the 
opposite side of the bladder, and a fourth course was given. The roentgen 
dose averaged 11,500 r as measured in air per patient. In many instances, 
the depth or tumor dose was better than 6000 r which is the level for which 
the authors strive. This dose was delivered with 200 kv. roentgen rays. 



Medical News Letter, Vol. 27, No. 8 



15 



composite Thoraeus filter, 50 ctn. target skin distance, 2.8 mm. copper 
half-value layer, through six pelvic ports and in fractions of 300 - 400 r 
daily. 

Eadon seeds were reserved for implantation of smaller tumor beds 
following fulguration of the tumor. The authors ordinarily use 1 mc. seeds 
with the usual 1 cm. distribution throughout the area involved, the implan- 
tation being done through the cystoscope. 

Radium implantation was used in larger areas or in nonres ectable 
tumors through a suprapubic incision. The implant, with low intensity nee - 
dies, was calculated to give a dose of 4000 to 5000 gamma r minimum to the 
affected area. The use of either radon or radium does not preclude the use 
of external irradiation and in all cases a roentgen dose of 6000 r should be 
the goal. 

Significant statistical results are compiled from these cases; twenty- 
four (29%) of them have survived for 5 years or more. 

Comparing these results with published results of other therapists, 
the authors believe that this program for treating patients with carcinoma of 
the urinary bladder is the most logical, safe, and, thus far, the most success- 
ful. The complications of fibrosis, strictures, and fistulae — so often used as 
an argument against radiation therapy — are not an inherent result of the method. 
They are rather the fault of the therapist who treats his cases too rapidly and 
without due vigilance as to the patient's response, (Lockwood, I. H. , Chapman, 
S. B. , Therapy of Carcinoma of the Urinary Bladder: Am. J. Roentgenol., 
75: 519-522, March 1956) 

iff Ifft iff ^ 

Operative Treatment of Pectus Excavatum 

Pectus excavatum is a congenital anomaly in which the body of the 
sternum is depressed to form a concavity which may reach to the vertebral 
bodies, or, passing to one side, into the paravertebral gutter. The lower 
costal cartilages on either side bend back toward the dorsally displaced 
sternum, giving breadth to the concavity, the depth of which is usually max- 
imal just above the xiphisternal junction. There is, therefore, a concavity 
from side to side and from above downward. The deformity is commonly 
noted soon after birth and the feature of greatest importance is the tendency 
toward progression. The degree and rate of progression are variable and 
inconstant. The concavity is conspicuous, unsightly, and a source of em- 
barrassment to young individuals of either sex. The deformity of the rib 
cage and the spine in the more severe instances is quite plain, even when 
the patient is clothed. These patients usually have a thorax with decreased 
anteroposterior diameter, a moderate dorsal kyphos, and carry their heads 
thrust forward. Paradoxical inward motion of the sternum with inspiratory 



16 



Medical News Letter, Vol. 27, No. 8 



movement is a conspicuous feature of the deformity in infants and children, 
until, with increasing years, the chest wall becomes rigid. This paradox- 
ical inspiratory motion of the sternum may be seen to an astonishing degree 
in infants with the deformity. There is commonly a prominent protrusion 
of the abdomen on inspiration. The etiology of the deformity is not well 
established. 

In some instances, the heart is compressed between the spine and the 
sternum, but more often, the depression of the sternum displaces the heart 
to the left, even in the less severe cases. In the more severe deformities, 
the heart is displaced far to the left and rotated posteriorly. Pushed out 
in the left hemithorax in a patient with a flat, thin chest the heart gives the 
impression of being imprisoned in the flattened chest between the anterior and 
posterior parietes — and, in fact, it may be so imprisoned. Such a degree of 
deformity does not often develop before adolescence, but it is not possible 
to predict which infant with pectus excavatum will go on to develop a severe 
deformity and which will not. 

Operation is undertaken to correct the existing deformity and to pre- 
vent its progress. The younger the patient at the time of correction, the 
more favorable are his chances of attaining a normal thoracic contour with 
subsequent growth of the rib cage. If the deformity is severe, or if a com- 
petent pediatrician has observed it to progress, operation is undertaken at 
any age. 

Operation is, therefore, undertaken for physiologic, orthopedic, and 
cosmetic reasons. If dyspnea, exercise intolerance, or cardiac arrhyth- 
mias are present, operation is strongly indicated. However, most children 
have no such symptoms and operation is generally advised even in their 
absence. In children with pronounced defects, operation should be xrnder- 
taken before there is any evidence of physiologic disturbances. One cannot 
predict which children will ultimately suffer most if not operated upon. On 
the other hand, one may say that a less formidable procedure in infancy will 
probably insure normal development, whereas more extensive operation some 
years later may produce only a partial correction of the deformity. 

The anteroposterior flattening of the chest and the kyphosis may im- 
prove or disappear if operation is performed early enough. The younger the 
patient, the simpler and smaller the procedure, and the better the results 
that may be expected. Corrective exercises cannot be expected to achieve 
much for an actual skeletal deformity such as this. 

The deformity itself is the source of concern to children and parents 
and the basis for teasing by playmates. A sunken chest, with the clothes 
worn by both sexes today, can scarcely be hidden, particularly in the summer- 
time. The extent to which a patient and his family have been disturbed has 
usually been fully appreciated only after the operation. Parents are apparently 
loathe to admit to wanting an operation of this character for what they construe 
to be cosmetic reasons, but the correction of the defect seems to permit the 



Medical News Letter, Vol. 27, No. 8 



17 



patient and family alike to discuss freely what had previously been minimized 
by a protective reticence. (Ravitch, M, M. , The Operative Treatment of 
Pectus Excavatum: J. Pediat. , _48_: 465-472, April 1956) 

3{C 3^ 9{< 3^ SfC 

Reunion at National Naval Medical Center 

A reunion of officers attached to the National Naval Medical Center 
during the period, 7 December 1941 to 15 August 1945, is being planned 
for the period 10-11 November 1956. Mrs. John Harper and LCDR 
Grace B. Lally (4002 Redden Road, Drexel Hill, Philadelphia, Pa. ) are 
members of a committee to obtain names, addresses, and expressions of 
interest of former officers attached to the Center. 

The Surgeon General has expressed an interest in assisting the com- 
mittee in planning their reunion. 

LCDR Lally will supply interested officers with full details of the 
planned reunion. (National Naval Medical Center) 

Residency Training in Allergy 

There will be a space available for a resident in Allergy at the U. S. 
Naval Hospital, San Diego, Calif., beginning April 1956. Applications are 
invited from Regular officers and Reserves who have completed their obliga- 
ted service. Prior training in Internal Medicine of one or more years is a 
prerequisite. (ProfDiv, BuMed) 

Penicillin Prophylaxis of Gonorrhea 

BuMedlnst 6222. 3B of 25 October 1954 has been interpreted by many 
as prohibiting the use of oral penicillin for the prevention of gonorrhea. This 
interpretation is incorrect. Medical officers are at liberty to use this chemo- 
prophylaxis as they desire and should not refuse it to those who request it 
only on the basis of this instruction. 

For the reasons set forth in that instruction, major emphasis on the 
prevention of venereal diseases should not be focused on chemoprophylaxis, 
since oral penicillin has been shown to be effective only in the prevention 
of gonorrhea, whereas the real Medical Department problem is bound up 
with other venereal diseases. 



^ 3^ j[c 3^ sjc 



18 



Medical News Letter, Vol. 27, No. 8 



THE UNITED STATES NAVY 

GUARDIAN OF OUR COUNTRY 

The United States Navy is responsible for maintaining control of the sea 
and is a ready force on watch at home and overseas, capable of strong 
action to preserve the peace or of instant offensive action to win in war. 

It is upon the maintenance of this control that our country's glorious 
future depends; the United States Navy exists to make it so. 

WE SERVE WITH HONOR 

Tradition, valor, and victory are the Navy's heritage from the past. To 
these may be added dedication, discipline, and vigilance as the watchwords 
of the present and the future. 

At home or on distant stations we serve with pride, confident in the respect 
of our country, our shipmates, and our families. 

Our responsibilities sober us; our adversities strengthen us. 

Service to God and Country is our special privilege. We serve with honor. 

THE FUTURE OF THE NAVY 

The Navy will always employ new weapons, new techniques, and 
greater power to protect and defend the United States on the sea, under 
the sea, and in the air. 

Now and in the future, control of the sea gives the United States her 
greatest advantage for the maintenance of peace and for victory in war. 

Mobility, surprise, dispersal, and offensive power are the keynotes of 
the new Navy. The roots of the Navy lie in a strong belief in the 
future, in continued dedication to our tasks, and in reflection on our 
heritage from the past. 

Never have our opportunities and our responsibilities been greater. 



Medical News Letter, Vol. 27, No. 8 



19 



From the Note Book 

1. The Military Medicine Section of the American. Medical Association's 
Annual Scientific Program will meet, June 12 - 14, 1956, in Chicago. 
Captain C. L. Andrews, MC USN, Secretary of the Military Medicine Section, 
stated that this year's important and extremely valuable program will include 
papers by leading military and civilian physicians and scientists from all parts 
of the nation. Reserve Medical officers (Inactive) of the Navy, Army, and 
Air Force will receive retention or retirement point credits for attendance. 
Eligible medical officers are urged to take advantage of this opportunity. One 
point will be awarded for each day attended. 

Rear Admiral H. L. Pugh, MC USN, Chairman of the Military Medicine 
Section, will present the opening address at 9:00 a.m. , June 12, 1956. 
(TIO, BuMed) 

2. Rear Admiral B. W. Hogan, Surgeon General of the Navy, recently 
announced that a complete Radioisotope Laboratory has been established in 
the Egyptian National Research Council Building, Cairo, Egypt. In support 
of the "Atoms for Peace" program, established by the President, the Radio- 
isotope Laboratory is to be used for medical treatment of the Egyptian people, 
(TIO, BuMed) 

3. Captain E. E. Hogan, MC USN, Director of Physical Qualifications and 
Medical Records Division, and Mr. Philip B. Wisman, Head of the Organ- 
ization and Methods Branch, Administrative Division, have been designated 
as representatives of the Bureau of Medicine and Surgery at the dedication 
ceremony of the new $16,000,000 Department of Defense Military Personnel 
Records Center, in St. Loms, April 17, 1956. Centralization of these records, 
together with the improved facilities of the new Center, will enable the Depart- 
ment of Defense to offer more efficient and expeditious record reference ser- 
vice. (TIO, BuMed) 

4. Captain W. L. Engelman, MC USN, has been elected a member of the 
National Council of the American Society of Military Comptrollers. Captain 
Engelman is Comptroller and Director of the Comptroller Division in the 
Bureau of Medicine and Surgery. (TIO, BuMed) 

5. Dr. G. B. Casey, Secretary, Council on Hospital Dental Service, Amer- 
ican Dental Association, has informed the Commanding Officer of the U. S. N. H. , 
Memphis, Tenn. , that its dental service has been approved by the Council. 
Captain CO. Williams, DC USN, is the Chief of Dental Service. (TIO, 
BuMed) 

6. Sufferers from cancer, their families, physicians, and all concerned 
with the care of cancer patients are hereby advised and warned that the 



20 



Medical News Letter, Vol. 27, No. 8 



so-called Hoxsey treatment for internal cancer has been found by the United 
States Court of Appeals for the Fifth Circuit, on the basis of evidence pre- 
sented by the Food and Drug Administration, to be a worthless treatment. 
(DHEW, PHS) 

7. The Public Health Service has placed contracts with five laboratories 
for large-scale screening of chemical compounds in the search for drugs 
useful in treating cancer. The laboratories are: Microbiological Associates, 
Bethesda, Md. ; Wisconsin Alumni Research Foundation, Madison, Wis. ; 
Southern Research Institute, Birmingham, Ala. ; Hazleton Laboratories, 
Falls Church, Va. ; and Stanford Research Institute, Menlo Park, Calif. 
{DHEW, PHS) 

8. The possibility of complications resulting from the use of intestinal tubes 
and drains is discussed. Six case histories are presented which illustrate a 
variety of unusual complications resulting from the use of intestinal tubes or 
abdominal drains. (Am. J. Surg., March 1956; J. K. Stevenson, M. D. , 

H. N. Harkins, M.D. ) 

9. Supervoltage roentgen therapy seems to offer nothing curative in cancer 
of the lung. There is evidence of significant palliation. It is suggested that 
nitrogen mustard combined with supervoltage radiation may be superior to 
radiation alone. {Am. J. Roentgenol., March 1956; T. A. Watson, M.D.) 

10. Peripheral artery embolization is a medical and surgical emergency. 
The difference between prompt action and unnecessary delay may mean the 
saving of a limb instead of a needless amputation. (Arch. Surg. , March 
1956; R.J. Frank, M. D. , L. Zaino. M. D. , L. Brown, M.D.) 

11. A method is presented for utilizing the urinary excretion or radioactive 
vitamin B12 in the diagnosis of Addisonian pernicious anemia. (Ann. Int. 
Med., March 1956; S. F. Rabiner, M. D. , et al) 

12. An article presents 4 cases of Ebstein's disease recognized during life 
and describes the characteristic features of this anomaly. (Am. J. Med. , 
March 1956; J. W Brown, M. D. , D. Heath, M. B. , W. Whitaker, M.D.) 

13. The cause of an often fatal metabolic disease of children has been dis- 
covered. Drs. H. M. Kalckar, E. P. Anderson, and K. J. Isselbacher, in 
work conducted at the National Institutes of Health, Bethesda, Md. , have 
unraveled much of the mystery surrounding the little understood children's 
disease, galactosemia, also known as galactose diabetes. (DHEW, PHS) 

3(c sflc 3^ 3^ 5^ 



Medical News JLetter, Vol. Z7, No. 8 



21 



Board Certifications 

American Board of Internal Medicine 

LTJG Mollis G. Boren MC USNR (Inactive) 

L.T John A. Broward MC USNR (Inactive) 

LT William P. Daines MC USNR (Inactive) 

LT Elvia E. Eddleman MC USNR (Inactive 

CDR Matthew J. M. Ellis MC USNR (Inactive) 

LT William I. Freud MC USNR (Active) 

LTJG WiUard G. Glass MC USNR (Inactive) 

LT Richard Gorlin MC USNR (Active) 

LTJG Wilson Greene, Jr. MC USNR (Inactive) 

LT Samuel H. Hay MC USNR (Inactive) 

LT William M. Hicks, Jr. MC USNR (Inactive) 

LT Fred M. Hunter MC USNR (Inactive) 

LTJG Benjamin F. Huntley, lU MC USNR (Inactive) 

CDR Jack T. Jones MC USN 

LCDR Nathan L. Marcus MC USNR (Inactive) 
LTJG Robert R. McBryde MC USNR (Inactive) 
LCDR Burch V. Raley MC USNR (Inactive) 
LT Stanley Reichman MC USNR (Active) 
LT Justin L. Richman MC USNR (Active) 
LTJG Clement P. Stodder MC USNR (Inactive) 
LCDR Daniel E. Yow MC USNR (Inactive) 

American Board of Obstetrics and Gynecology 

LTJG James E. Covell MC USNR (Inactive) 
LTJG John D. Degenhardt MC USNR (Inactive) 
LT William J. McCann MC USNR (Inactive) 

American Board of Orthopedic Surgery 

LTJG Lawrence L. Thompson, Jr. MC USNR (Inactive) 

American Board of Otolaryngology 

LCDR Byron T. Eberly MC USN 

American Board of Pathology 

LT Gilbert H. Friedell MC USNR (Active) 
LT Leonard S. Gottlieb MC USNR (Active) 
LTJG William S. Orr, Jr. MC USNR (Inactive) 



American Board of Radiology 

CDR Francis H. Holmes MC USN (Radiology) 

CDR Lorraine E. Walters MC USN (Diagnostic Roentgenology) 



2Z 



Medical News Letter, Vol. 27, No. 8 



American Board of Surgery 

LTJG Thomas H, Connell, Jr. MC USNR (Inactive) 
LTJG Merlin K. DuVal, Jr. MC USNR (Inactive) 
LTJG Worthington G. Schenk, Jr. MC USNR (Inactive) 
LCDR Theodore H. Wilson, Jr. MC USN 

American Board of Urology . . ' 

LT Robert G. Marks MC USNR (inactive) 
LT James 1. Tyree MC USNR (Inactive) 

* J(c * * ;je * 

Recent Research Pro jects 
Naval Medical Research Institute, NNMC, Bethesda, Md . 

1. The influence of Specific Chemical Modification upon the Physical and 
Immunochemical Properties of Proteins I: The Effect of Guanidination upon 
the Interaction of Human Serum Albumin with Rabbit Antibodies. NM 000 018 
06. 43, 15 October 1955. 

2. Some studies on the Influence of Light On the Mating Activity of Anopheles 
Quadrimaculatus Say. NM 005 048. 06. 07, 25 October 1955. 

3. Oxygen Toxicity and the Nerve Impulse, NM 004 005. 09. 01, 7 Nov. 1955. 

4. Studies on the Use of Virulent Treponema Pallidum Syphilis. NM 005 048 
17.02, 8 November 1955. 

5. Pharmacological Studies on Irradiated Animals. IV Water Intake of Guinea 
Pigs as a Parameter for Oral Drug Administration in Experimental Radiation 
Therapy. NM 006 012.05. 15, 8 November 1955. 

Naval Dental School, NNMC, Bethesda, Md . 

1. A Pilot Research Study on the Development of a Low-Vacuum, High Air- 
Speed Aspirator. NM 008 015 (Pilot), 1 November 1955. 

2. Mandibular and Maxillary Grafts, NM 008 015. 05— Rebuilding the Re- 
sorbed Alveolar Ridge. NM 008 015.05.01, 12 January 1956 

Naval Dental Research Facility, Great Lakes, 111. 

1. Clinical Evaluation of Pulpotomy in Young Adults. NM 008 013. 10. 03, 
December 1955. 

2. Lysozyme: Its Occurrence and Nature in Human Parotid and Whole Saliva 
NM 008 013. 12.06, December 1955. 

3. Studies on Influenza Virus After Storage at 4° C for Periods up to 5 Years 
NM 005 051.06.08, December 1955. 

4. The Use of Solubel Antigen for the Serological Diagnosis of Influenza in a 
Vaccinated Population. NM 005 051.06.07, December 1955. 



Medical News Letter, Vol. 27, No. 8 23 

Naval Medic al Research Laboratory, Submarine Base, New London, Conn. 

1. An Evaluation of Ear Defender Devices. Report No. 271. NM 003 041. 
56.06, 15 December 1955. 

2. Effect of Increased Atmospheric Pressure upon Hearing. NM 002 014. 
06.03, 21 December 1955. 

3. Effect of Increased Atmospheric Pressures upon Intelligibility of Spoken 
Words. Memo. Report No. 55-8. NM 002 014.06.04, 22 December 1955. 

(Additional Research Projects will be listed in next issue) 

s^c 4: :{( 4: 

BUMED INSTRUCTION 6320. l6A 19 March 1956 

From: Chief, Bureau of Medicine and Surgery 

To: U.S. Naval Dispensaries 

All Continental Activities Having Station Hospitals or Dispensaries 
All Extracontinental Activities Having Station Hospitals or 
Dispensaries with Authorized Beds. 

Subj: Staffing Report, NavMed 1357 (Report Symbol Med 6320-7) 

End: (1) Staffing Example with Exhibit I 

This instruction requests information on staffing as it relates to workload. 
The information is required for budgetary and administrative uses by the 
Bureau and other components of the Department of Defense. BuMed Instruc- 
tion 6320. 16 (Notal) is canceled upon submission of the March 1956 report. 

* 3|c :(c 4: :^ 

BUMED NOTICE 6710 22 March 1956 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical/Dental Personnel Regularly 
Assigned 

Subj: Antibiotics; extension of potency dates 

Ref: (a) Medical and Dental Materiel Bulletin (MDMB) Edition No. 64 

of 1 March 1956 i 

This notice provides authority to extend the potency dates of certain anti- 
biotics. 



24 



Medical News Letter, Vol. 27, No. 8 



BUMED INSTRUCTION 6710.2-8 22 March 1956 

From: Chief, Bureau of Medicine and. Surgery 
To; All Ships and Stations 

Subj: Defective medical and dental material; authority for disposition of 

Ref: (a) Medical and Dental Materiel Bulletin, Edition No. 64 of 1 Mar '56 
(b) Art 25-21 ManMed 

This instruction provides authority for the disposal of defective material 
listed in paragraph IV of reference (a). 




DEINfTAl X ^^M^ 7 SECTIOIV 



Inspector General. Dental, Visiting Dental Installations 
in European and Middle East Mediterra nean Areas 

Rear Admiral Herman P. Riebe, DC USN, Inspector General, Dental, 
accompanied by his Executive Assistant, Lieutenant Commander Irvin D.Cox, 
MSC USN, is visiting dental installations in the European and Middle East 
Mediterranean areas during the period 4 April to 1 May 1956. 

Dental facilities in London, England; Bremerhaven, Germaiiy; Athens, 
Greece; Naples, Italy; Cairo, Egypt; Port Lyautey, French Morocco; Rota, 
Spain, and Malta are on Admiral Riebe 's itinerary. 

Visit to Naval Training Center, Ba inbridge 

Members of the Department of Defense Dental Advisory Committee will 
visit dental facilities of the Naval Training Center, Bainbridge, Md. , on 
30 April 1956. The purpose of this visit is to obtain first-hand information 
on dental facilities and dental service rendered to recruits during the training 
phase. The committee will also discuss dental problems of mutual interest 
that may exist with the local dental officer s . Scheduled to make the visit are: 
Dr. Thomas P. Fox, Chairman, Dr. Daniel F. Lynch, Dr. Francis J. Reich- 
mann, Rear Admiral Ralph W. Malone, DC USN, Brigadier General Marvin 
E. Kinnebeck, USAF (DC), and Major General Oscar P. Snyder, DC USA. 



Medical News Letter, Vol. Z7, No. 8 
"Mr. Disaster" on Nationwide TV Program 



25 



Captain John V. Niiranen, DC USN, U.S. Naval Dental School, NNMC, 
Bethesda, Md. , presented the U.S. Naval Dental Corps Casualty Treatment 
Training Manikin, "Mr. Disaster, " on a live television show "You Asked 
for It, "in Los Angeles, Calif. , on 9 April 1956. This presentation was then 
shown nationwide over a national TV network on the same program on 15 April 
1956. The theme of the presentation emphasized the Navy's Dental Corps con- 
tribution for training in the care of mass casualties. "Mr. Disaster" had his 
debut before an estimated 20 mi,llion viewers on the nationwide program. 

:{( ^ :{( i|c :{( :(c 

Dental Officers Selected for Postgraduate Course 



Twenty -one Naval Dental officers have recently been selected for the 
General .Postgraduate Course convening in September 1956 at the U S. Naval 
Dental School, NNMC, Bethesda, Md. They are: 

CDR Lloyd M. Armstrong, DC USN 

CDR James J. Brown, Jr. , DC USN 

CDR John F. Bucher, DC USN 

CDR Frank Doboronte, DC USN 

CDR Arthur E. Gustovson, DC USN 

CDR Thomas H. Mayo, DC USN 

CDR Walter E. Ralls, DC USN 

CDR Robert M. Williams, DC USN 

LTCDR Melvin L. Colton, DC USN 

LTCDR Everard F. Jones, Jr. , DC USN 

LTCDR Clifford H. Prince, Jr. , DC USN 

LTCDR Michael Zustiak, DC USN 

LT Gordon P. Baxter, DC USN 

LT Bernard (n) Chap, DC USN 

LT Lee A. Counsell, DC USN 

LT Harold N. Glasser, DC USN - 

LT Jack D. Mahoney, DC USN 

LT William B. Shreve, DC USN 

LT Paul J. Sydow, DC USN 

LT Maury E. Wortham, DC USN 

sjc 3^ 3^ 3^ 



The printing of this publication has been approved by the Director 
of the Bureau of the Budget, 16 May 1955. 



26 , Medical News Letter, Vol. 27, No. 8 

Examinations for Board Certification in 
Prosthodontics and Periodontology 

The annual examination for certification by the American Board of 
Prosthodontics will be held in Milwaukee, Wis. , during the period, Septem- 
ber 2 - 8, 1956, at the School of Dentistry, Marquette University. 

The second half of the examination for certification by the American 
Board of Periodontology will be held in Indianapolis, Ind. , during the period 
12-13 April 1956, at the School of Dentistry, Indiana University. 

Dental Division (BuMed) Affiliate Member of 
American Association of Dental Schools 



During the annual meeting of the American Association of Dental 
Schools recently held in St. Louis Mo. , the Dental Division, Bureau of 
Medicine and Surgery, Navy Department, was voted an affiliate membership 
in the Association in recognition of the Navy's Dental Officer Training Pro- 
gram. 

j(! S{C S^! Sjc 3^ * 

Dental Intern Training During Fiscal Year 1957 

Three naval hospitals will be added to present listing of naval hospitals 
conducting programs of Dental Intern Training with the starting of fiscal year 
1957. Listed below are naval hospitals* which will conduct Dental Intern 
Training Programs during the fiscal year 1957: 

* U. S. Naval Hospital, Camp Pendleton, Calif. 
U.S. Naval Hospital, St. Albans, L. I. , N. Y. 
U.S. Naval Hospital, Philadelphia, Pa, 
U.S. Naval Hospital, Portsmouth, Va. 

U.S. Naval Hospital, Great Lakes, 111. 

U.S. Naval Hospital, San Diego, Calif. 

U. S. Naval Hospital, Oakland, Calif. 

* U. S, Naval Hospital, Chelsea, Mass, 
*U.S. Naval Hospital, Corona, Calif. 



^ ^ ^ ^ ^ 



Medical News Letter, Vol. 27, No. 8 
DT Training Requirements after 1 July 1956 



27 



The classes which will graduate from the Class "A" Dental Technicians 
Schools on 8 June 1956 are expected to bring the number of dental technicians 
up to authorized strength for the first time since January 1955. This will re- 
sult in reduced requirements for dental technician training beginning 1 July 
1956. In view of the reduced requirements, volunteer candidates or dental 
strikers who submit requests after 4 May 1956 will not be granted a waiver 
on the combined GCT/ARI test below 90. 

All dental officers who contemplate recommending dental strikers for 
dental technician training with combined scores of less than 90 should have 
these personnel submit a request for the school immediately. 



Sjc jji 5^ )|C Sjc 

Dental Interns Selected for Fiscal Year 1957 

The following eighteen dental students. Ensign (1995), from civilian 
dental schools have recently been selected for appointment in the Dental Intern 
Training Program for the fiscal year 1957: 



Nam e 

Albers, Delmar Dean 
Baker, Ronald Dale 
Brown, Kenneth Edward 
Coombs, Paul Spencer 
Eichel, Frederick Pecht 
Gordon, Jim Dudley 
Kieny, Richard Joseph 
Lattner, Richard Alfred 
Mainous, Elgene George 
McLeod, Carlton Joseph 
Marsalek, Daniel Eugene 
Ott, Robert John 
Parent, Clarence Bernard, Jr. 
Scharpf, Herbert Otto 
Thompson, Leon Talmadge, Jr. 
Williams, Sherman Luther 
Wyne, Gene Kenyon 
Valasek, Arden Dale 



School 

University of Iowa 
University of Pittsburgh 
University of Buffalo 
Georgetown University 
University of Pittsburgh 
University of Iowa 
University of Nebraska 
University of St. Louis 
Ohio State University 
University of Maryland 
Western Reserve University 
Georgetown University 
University of Loyola (Nola) 
University of Maryland 
Emory University 
University of Pittsburgh 
University of So. California 
University of Nebraska 



28 



Medical News Letter, "Vol. 27, No. 8 




MEDICAL RESERVE SECTION 



Navy's New Research Clerkship Training Program 

Sixty-day active duty for training at Naval Medical Research Activities 
is now available to medical students commissioned as Ensigns (1995), U.S. 
Naval Reserve, who have successfully completed their first year of medical 
school. 

Known as the Navy's Research Clerkship Training Program, these 
clerkships offer a detailed review of the specific Research Program being 
conducted at the training activity. A part of the training will be spent in each 
research department and the trainee will serve as an assistant in actual labor- 
atory research on one specific project underway at the time. In addition to 
providing summer employment for the undergraduate medical student, these 
clerkships offer valuable orientation and indoctrination into medical research 
as well as on-the-job training commensurate with the individual's professional 
attainm ents. 

This program begins 1 July each year and ends 30 June of the subse- 
quent year. It is authorized for up to, and including, 60 days' active duty 
with full pay and allowances and has been established at the following Naval 
Medical Research Activities in the quotas listed below: 



Activity 



District 



Quota 



Naval Medical Research Laboratory 
Submarine Base 
New London, Conn. 



1 

3 



4 
4 



Aviation Medical Equipment Laboratory 
Naval Air Material Center 
Philadelphia 12, Pa. 



4 
5 



3 
1 



Aviation Medical Acceleration Laboratory 
Naval Air Development Center 
Johnsville, Pa. 



5 
9 



1 
2 



U.S. Navy Experimental Diving Unit 
Naval Gun Factory 
Washington 25, D. C. 



5 

PRNC 



2 
3 



Medical News Letter, Vol. 27, No. 8 



29 



Activity District Quota 

U.S. Naval Medical Research Institute 3 1 

National Naval Medical Center 4 1 

Bethesda 14, Md. 5 2 

9 5 

PRNC 3 

U.S. Naval School of Aviation Medicine 6 2 

Naval Air Station 8 2 
Pensacola, Fla 

U.S. Naval Medical Research Unit No. 4 9 6 
Naval Training Center 
Great Lakes, 111. 

U.S. Naval Medical Research Unit No. 1 11 2 

Life Sciences Building 12 1 

University of California ^13 1 
Berkeley 4, Calif. 



Eligible and interested officers should make application to their Dis- 
trict Commandant (Medical Reserve Prograin Officer) at the earliest prac- 
ticable date. Early application will insure prompt processing of requests 
and forwarding of active duty orders. 

ijc 3(s sjc s[c )Sc ^ 

Training in Submarine Medicine - Active Duty 

Fourteen days' active duty for training in Submarine Medicine for 
eligible Medical Reserve and Medical Service Corps officers is available 
at the Medical Research Laboratory, Naval Submarine Base, New London, 
Conn. , beginning 7 May 1956. 

This on-the-job training presents an up-to-date review of problems 
relating to Submarine Medicine and recent developments in Submarine Re- 
search. 

Orders should direct the trainee to report prior to 1600 on the day 
preceding the convening of the course. Ten days' advance notice is necessary 
so that accommodations for trainees may be made available. Quarters, Mess- 
ing and off-duty recreational facilities are available on the base. Off-station 
accommodations are very limited, facilities for families difficult to find, 
and expensive. However, New York City and Boston are accessible by auto 
or train. Secret clearance is required. 



30 



Medical News Letter, Vol. 27, No. 8 
AVIATION MEDICINE SECTION 




Excerpts from Medical Officers Report of Aircraft 
Accidents and Incidents 



Case No. 1 - F2H-3 - Damage: C - Injury Class: E 

Pilot took off feeling "not too good, but good enough for hop. " (Pilot 
was instructed by the flight surgeon the evening before the incident to con- 
tact the flight surgeon following morning if pilot were scheduled to fly.) 
Insofar as the pilot could tell, his flying was satisfactory on a routine 
gunnery hop until the 5th gunnery pass on which pilot collided with banner. 
Pilot's return to base and subsequent landing was uneventful. 

This report is submitted because the flight surgeon feels that, though 
the medication taken may not have been the causative factor of the incident, 
it was a contributing factor. Cognizance is made that collisions with 
banners have occurred with pilots in an excellent physical and mental status. 

Pilot consulted flight surgeon evening prior to incident about a head cold. 
He was advised that if certain medications were given to him, it would be 
necessary to ground him. Pilot, nonetheless, contacted a friend and ob- 
tained some Benadryl capsules (50 mgm. ) and some capsules from a box. 
Instructions on box stated "do not fly for 24 hours after taking. " Pilot took 
medications and on gunnery hop flew into banner doing class "C" damage 
to aircraft. He stated, when he broke off target, he felt he would easily 
clear same as he completed his gunnery run. Subsequent discussion with 
pilot of incident brought out statement, "I've learned my lesson now. Some- 
how, I thought you doctors were exaggerating the effect of these drugs on 
the body. " Pilot did not report to flight surgeon immediately after incident. 
His commanding officer stated that pilot's sensorium seemed clouded and 
slightly hazy after landing when he questioned him. 

Case No. 2 - F9F-5 - Damage: C - Injury C lass: E 

(Note: The Weekly Summary of Major Aircraft Accidents, published by the 
U. S. Naval Aviation Safety Center, indicates that progress is being made 
toward the goal of an over all major aircraft accident rate of 3. in 1956 
in all categories except wheels -up landing accidents. ) 



Medical News Letter, Vol. 27, No. 8 



31 



On routine flight and landing, pilot dropped flaps and failed to lower 
gear. He touched down after one -third of the runway elapsed, heard the 
scraping, added full power, felt the aircraft go into an abnormal nose 
high, Ipft banked attitude at an altitude of about 20 ft, , cut the power, 
leveled the wings, and landed ahead. He continued to slide with little 
drop in airspeed to about three -fourths of the runway when he tightened 
safety harness and dropped tail hook and lowered gear. The plane stopped 
about 700 feet short of the end of the 8000-ft. runway. The pilot was \m- 
harmed. 

This man has had a culmination of conditions. This was his third hop 
of the day. He was on duty since 0730 this AM. He had a good breakfast, 
but only a sweet roll and milk for lunch and nothing for supper because he 
"just didn't have an opportunity and he just didn't feel hungry. " He had been 
on normal oxygen throughout the flight except for 100% during the take-off 
check-off since it had been recommended at night vision school. He was 
on normal oxygen at the time of the accident. 
The flight surgeon recommends: 

(1) That pilots and operations personnel give attention to scheduling 
of flight so that pilots will receive sufficient nutrition and rest prior to 
their flights. 

(2) That whenever a distraction occurs during landing, pilots be 
informed of the necessity for extra caution in completing their check-off 
lists. 

(3) That a visual indicator be provided so that ground personnel may 
check gear condition during night landings. 

Case No. 3 - AD-6 - Damage: A - Injury Class: E 

While crossing south leg of range station, after X/C flight, checked 
aircraft by switching to #1 inverter, mixture rich, and set up cockpit. 
Throttled back to 20" on break, slowed to 130 knots on downwind leg, let 
down to 1000 ft. , put down flaps (full) and pitch in high at the 180. He did 
not use check-off list for last three items (pitch, flaps, and wheels). His 
custom was to lower gear at break. However, at this time, he was putting 
his running lights from flashing to steady bright. He recalls looking down 
at hydraulic pressure and noting pressure was up. He does not remember 
at any time consciously looking at gear indicator or putting the gear handle 
in a down position. First indication of trouble was after flare -out when he 
noticed sparks coming from prop hitting rimway, followed by flame from 
the starboard side of engine. Evacuated aircraft promptly after coming 
to rest. Crash crew responded promptly. 

This accident is another in a long Navy-wide series of wheels-up 
landings due to pilots' not thinking or as a result of mechanical flying, i. e. , 
assuming the gear down and locked after an interruption of the sequence of 
habit patterns. 



32 



Medical News Letter, Vol. 27, No. 8 



Prolonged interview in this case revealed no psycho-physiological 
causes for the pilot error. Actually, this pilot was most satisfied with his 
flight since everything went smoothly, that is, until he attempted to land with 
gear up. There was no rush to get home, no domestic or financial difficul- 
ties referable to a cause for the accident. Actually, the pilot states that 
he does not remember lowering the gear or checking the gear indicator. His 
first indication of trouble was noting sparks when the prop dug into the run- 
way, followed immediately by fire. 

The old "saw" that the flight is never over until the plane is safely in 
the barn holds true here. 

There was no wheel-watch available as the accident occurred at night 
and on a weekend. 

It is recommended that in an effort to pare down the number of wheels - 
up landings, whether or not a wheel -watch is posted, the following plan be 
adopted: 

Heretofore, when a pilot at the 180° reports to the tower, "Wheels 
down and in the green, " the tower operator would roger the transmission. 
If the tower operator would, instead of rogering this transmission, reply 
with a positive and emphatic statement such as, "Please check your gear 
handle and indicator visually and report in, " it is felt that the pilot's atten- 
tion would be directed toward making a definite check of his gear prior to 
landing. Granted, this will not get the proverbial 10%, but even a 50% reduc- 
tion in wheels -up landings would effect tremendous savings to the Navy. 

Case No. 4 - F9F-8 - Damage: A - Injury Class: E 

This pilot was returning from a routine utility flight and was making a 
straight-in approach to the field and had completed his landing check-off 
list except for wheels and flaps, when the control tower told him to continue 
and make a routine break over the field. He was then told to break "long" 
over the field. During this time, he was keeping a sharp lookout for other 
aircraft in the pattern, since there was moderate haze present. He intended 
landing on 32 L. While he was in this approach, an aircraft blew a tire land- 
ing on 32L, and 321- was closed by the tower. He decided to land short due 
to the tower notifying an aircraft coming in on a straight-in approach to 32R 
that the arresting gear was rigged. He then called, "Turning base, gear 
down and locked, " and has no recollection of actually looking at the indicator. 
He was more occupied with airspeed and altitude and avoiding other aircraft. 
He centered his attention on the end of the runway, not observing the wheel- 
watch and set the aircraft down on the end of the runway. The wheels were 
not down on landing. The aircraft slid on the runway, suffering minor 
damage. The safety equipment functioned well and the pilot was uninjured. 

The wheel-watch stated that he had waved his flags prior to touchdown, 
and flares were observed by the tower just as the aircraft passed the wheel- 
watch. The pilot did not observe these flares or the flags. 



Medical News Letter, Vol. Z7, No. 8 



33 



There were no sociological or physiological factors pertinent to this 
accident. Psychologically, this pilot is a stable individual. I believe that 
the primary factor in this accident was that the pilot was distracted by the 
numerous transmissions from the tower, and by having to be constantly 
on the alert for other aircraft in the pattern which he could not see due to 
the haze. He had had his mind set on a straight -in approach originally and 
was saving wheels and flaps for the last as he normally did. His train of 
thought was then interrupted several times by the subsequent events, so 
that by the time he called "gear down and locked, " he had forgotten that 
he had not put his gear down. The fact that his flaps were down when he 
landed indicates that his train of thought was interrupted at the time he 
normally would have put his gear down, and that, following this distraction, 
he completed the rest of the landing normally. 

]^ sje sic :ic ijc :{c 

Hyperventilation Syndrome 

A patient in the throes of hyperventilation syndrome may look and feel 
as if he were dying. At first, he may experience air hunger and a strange, 
apprehensive feeling of unreality, and then he may go onto dizziness, faint- 
ness, and a feeling of being utterly powerless; he has pain or tightness in 
the chest, pounding of the heart, numbness and tingling of the face and ex- 
tremities, cramps and muscular stiffness. Occasionally, such an episode 
goes on to complete loss of consciousness or, more rarely, to overt tetany. 

If examined during an attack, he is found to be pale, clammy, and 
cold, his pulse rapid and thready, and his blood pressure low, suggesting 
shock. Positive Trousseau and Chvostek signs may be elicited although 
the blood calcium level is normal. The syndrome is not so transient as 
ordinary syncope; it usually lasts for 10 minutes or longer, and recurs at 
variable times and frequency. When associated with effort, the episode takes 
place after rather than during the effort. The syndrome, whether terrifying 
or mild, is not rare. Raymond L,. Rice (Marquette University School of 
Medicine) found an incidence of 10.7% among 1000 ambulatory patients. 

The syndrome of hyperventilation is due precisely to that, yet the 
patient is not aware of hyperventilation; instead he is under the impression 
that he is short of breath; he senses air hxmger. When seen in the office, 
however, he usually shows sighing respirations and excessive yawning. 
Indeed, these may often be a first clue to the diagnosis. 

Hyperventilation is usually a manifestation of an anxiety state, but cere- 
bral damage (as with encephalitis) may also disturb the respiratory center 
and cause overbr eathing. Whatever the reason for hyperventilation, when 
sufficient carbon dioxide is blown off, a respiratory alkalosis is produced, 
and it is to this that the varied symptomatology of hyperventilation is due. 



34 



Medical News Letter, Vol. 27, No. 8 



The low CO2 content of arterial blood is held responsible for cerebral 
and peripheral vasoconstriction and for impaired dissociation of oxyhemo- 
globin. Vasoconstriction leads to a degree of cerebral anoxia, decreased 
cerebral blood flow, and increased cerebrovascular resistance. There are 
even electroencephalographic changes during the biochemical and sympto- 
matic derangements of hyperventilation. The paresthesias and muscular 
manifestations, including tetany, are apparently due to peripheral neuro- 
vascular effects which result from vasoconstriction locally. The atypical 
chest pains are probably due to spasm of intercostal, pectoral, or diaphrag- 
matic muscles during the state of alkalosis. The electrocardiogram at the 
time of an episode reveals significant depression of T waves and ST segments; 
these waves are reversible upon recovery and they can be reproduced by vol- 
untary overbreathing. 

Many so-called cases of hypoxia are, in all probability, really examples 
of hyperventilation. Flight surgeons should warn pilots of this danger when 
lectures are given on oxygen equipment. (Pfizer Spectrum: J. A. M. A. 
159: 28, December 3, 1955) 



:Ie # :^ 9|c 

Student Flight Surgeons to So lo Again 

Medical officers, undergoing training to be naval flight surgeons, have 
recently been granted authority to solo naval aircraft, provided they are 
physically qualified and meet proficiency requirements. The authority was 
granted by the Chief of Naval Operations and states that the flight surgeons 
will be authorized one solo flight in a T-34 Trainer plane. 

The flight experiences of student flight surgeons have varied with 
operational demands, time requirements, and other variables during the 
past years. Prior to World War II, naval flight surgeons received their 
basic specialized medical training at the Army Air Corps School at Randolph 
Field, Texas. Later, these graduates received indoctrination flying at Pen- 
sacola. After the establishment of the Naval School of Aviation Medicine at 
Pensacola in 1939, flight surgeon students who were regular naval officers 
received flight indoctrination. Reserve officers were graduated as Aviation 
Medical Examiners rather than flight surgeons and were expected to acquire 
their flight experience at their first duty station after leaving the school. 
Land planes, used in this training, were the N2S and the N3N1. The N3N on 
floats was the seaplane which qualified regulars could solo. 

Beginning with Class #22 in the summer of 1943, the opportunity for 
flight training was determined not by whether the medical officer was regular 
or Reserve, but rather by his physical qualifications, his motivation, his 
class standing, and the decision of the informal board which interviewed all 
eligible students . Usually about half of the students in each class got the 
flight experience. 



Medical News Letter, Vol. Z7 , No. 8 



35 



Shortly after World War II, seaplanes and flying boats were trans- 
ferred to Corpus Christi, Texas, and flight training for student naval flight 
surgeons was restricted to the N2S. Hours allotted were reduced by official 
orders from the previous 65 or 70 to less than 20. 

In the fall of 1947, Class #49 encountered a change for the better as 
student flight surgeons were for the first time given their training in the SNJ. 
Twenty-four hours of instruction in A -Stage led to solo flight in the SNJ for 
all who qualified. Additional training in tactics and advanced training in 
attack planes meant that students had over 42 hours in single-engined planes. 
Sixty-nine periods of ground school instruction and a 10 -hour navigation 
flight in a multi -engined plane completed the then current syllabus. 

By Class #51 the advanced phase was being given in the Corpus Christi 
area and included a flight to Panama or the Caribbean. Rocket firing runs 
.and GCA had been introduced by this time. 

This program continued until the Korean war necessitated a reduction 
in the total hours allotted both the academic and the operational phases of the 
student flight surgeon's training. The medical postgraduate training was con- 
densed from 6 months to 4 months, and the flight phase from 3 months to 6 
weeks. The multi -engined training was discontinued. 

In 1951, as helicopter pilots demonstrated their essential role in rescue 
operations in Korea, it became obvious that flight surgeons should have fam- 
iliarization training in rotary wing aircraft. In the summer of 1951, Class 
#60 was the first to receive such helicopter familiarization. The flight course 
at this time included 27 hours of single engine experience and 5 hours in heli- 
copters, backed up by 73 hours of ground school work. 

Solo flying had to be eliminated when the war forced a speed-up of 
training for the doctors. 

Now that the SNJ airplane has been replaced by the T-34B and the T-28 
has been integrated into the regular training program for naval aviators, 
another change appears. Members of Class #78, which recently completed 
graduate medical training at the school, have entered the flight phase. They 
are the first class to receive this instruction in the new T-34's. All who 
are physically qualified will receive instruction, and those who demonstrate 
satisfactory proficiency will be allowed, to solo. Such training is an important 
part of the young flight surgeon's experience before he goes out to the fleet 
air groups and squadrons. Here, as a flying crew member, he serves all 
the flying personnel of the command, both aviators and enlisted aircrewmen. 
The indoctrinational flight training is an important aspect of his preparation 
since it provides the young medical officer a means of identification with 
the aviator and a keener appreciation of morale within the air group and 
fosters a doctor -patient relationship which is so vital in a military setting. 
(Service Information Office, U.S. Naval School of Aviation Medicine, Naval 
Air Station, Pensacola, Fla. ) 



s(: :tc 9|c 9}: 3{c 



36 



Medical News Letter, Vol. 27, No, 8 



Air Travel and the Ambulatory Patien t 

Transportation of patients by air is a dual problem. One of these is 
movement of critically ill individuals or stretcher cases for whom special 
equipment, attendants, and detailed arrangements must be provided. The 
other, which is the subject of this article, has to do with the ambulatory 
patient who is to travel as an ordinary passenger on a commercial airline. 

In recent years, travel of the latter type has reached major proportions. 
During 1954, it is estimated that approximately 1,000,000 of the 34,500,000 
passengers flown by the regularly scheduled airlines of the United States 
were suffering from some disease or disability ranging in type and severity 
from the common cold to the advanced stages of cancer. These figures serve 
to explain why physicians are increasingly being asked to advise their patients 
with reference to air travel and suggest that all clinicians should be fully qual- 
ified to deal with this subject. 

While the great majority of ambulatory patients can fly on commercial 
airlines without suffering any ill effects, there are some important exceptions 
to this general rule. There are also cases in which a careful evaluation of 
all the circumstances will be necessary before a decision is made. 

Whether any given patient should travel by air depends on a number of 
conditions in addition to the type and severity of the patient's ailment. For 
example, one must take into account certain advantages as well as any dis- 
advantages of air travel, pertinent health laws and air transport regulations, 
the comparative safety of flight and, finally, the possible effects of aerial 
environment on the disease entity concerned. 

The question of whether the patient should travel by air or by some 
other means is seldom a purely academic matter. One of the most important 
considerations is to save time in reaching a specialized medical center when 
the immediate treatment of an acute illness or injury is deemed necessary. 
In traveling to distant points for recreation, rest, or convalescence, many 
patients find that air travel is the most convenient and comfortable as well 
as the least fatiguing, and this enhances their general well-being. In addition 
to considerations related to health, many ambulatory patients desire to fly 
for economic or business reasons. 

Travel by patients suffering from a contagious disease comes under the 
jurisdiction of the U.S. Public Health Service; such patients are not accep- 
table for transportation on any type of public conveyance, including aircraft. 

Mo st airlines also conform to a regulation of the Air Transport Assoc- 
iation of America that reads: "Participating carriers will refuse to carry, 
or will remove en route, any person whose status, age, physical or mental 
condition is such in the opinion of the participating carrier as to render him 
incapable of caring for himself without assistance, contributing to the dis- 
comfort of, or making himself objectionable to, the other passengers, or 
involving any hazard or risk to himself, to other persons, or property. " 



Medical News Letter, Vol. 27, No. 8 



37 



This regulation is designed to eliminate as ordinary passengers those 
patients who cannot be transported safely by any means and those who can be 
transported by air, but require facilities or attendants not normally avail- 
able on commercial aircraft. It should be kept in mind, however, that this 
latter type of patient may sometimes be accommodated by the airlines if 
proper prior arrangements are made for the necessary special attendants. 
Also, there are over 200 local flying services throughout the United States 
that have charter aircraft especially equipped to fly those who are seriously 
ill. 

Commercial aviation today is much safer than is generally realized. 
During 1954, as has already been stated, the airlines of the United States 
carried some 34,500,000 passengers. When the airlines' accident fatality 
rate for that year is compared with those of other forms of transportation on 
a passenger-mile basis, we find that while air travel was slightly more hazar- 
dous than bus or steamship travel, it was safer than travel by railroad, ground 
ambulance, or private automobile. It is thus quite evident that, rather than 
being relatively dangerous as sometimes assumed, scheduled commercial 
flying compares very favorably with other means of public or personal trans- 
portation. 

Airlines are forbidden by Civil Air Regulations to exceed certain limits 
of performance that might endanger the health and lives of passengers. It is 
for this reason that we can predict fairly accurately the type and degree of 
deviation from normal to which a patient traveling by air may be subjected. 
These deviations are only two in number. The first is airsickness, which 
is clinically identical with car sickness, trainsicknes s , and seasickness and, 
thus, is not peculiar to flying. Etiology and symptomatology of motion sick- 
ness are too well known to require elaboration here. The second factor that 
must be taken into account is the maximum altitude to which the patient may 
be safely exposed. This factor is significant for two reasons. It determines 
the maximum expansion of the gases contained in the closed body cavities 
resulting from the decreased atmospheric pressure with ascent. It also 
determines the maximum degree of hypoxia that may be anticipated. 

Essentially, all airplanes used on the principal domestic and overseas 
routes are equipped with pressure cabins. Existing Civil Air Regulations 
require that these airplanes be capable of maintaining a cabin pressure not 
exceeding that equivalent to 10,000 ft. altitude regardless of the actual altitude 
at which the airplane itself may be operated. Accordingly, passengers in this 
type of aircraft will not normally be exposed to more than 10,000 ft. conditions 
and it usually is considerably less than this. 

In the conventional airplane, used principally on short "feeder" routes, 
flights are generally made at moderate altitudes. However, it may some- 
times be necessary to fly up to 15, 000 ft. or slightly higher to get over storms 
or high mountains. To protect the passengers from excessive hypoxia on 
these occasions. Civil Air Regulations provide that on any flight, which is to 



38 



Medical News Letter, Vol. 27, No, 8 



exceed 8000 ft. , a supply of oxygen must be available for use if necessary. 
Thus, in this type of airplane a patient might be exposed to decreased pressure 
effects and hypoxia produced by exposure to 15,000 ft. altitude, except that 
above 8000 ft. hypoxia can be. entirely eliminated if the available oxygen is 
requested and used. 

Deciding whether any given patient may travel by air as an ordinary 
passenger is greatly simplified if various altitudes are converted to their 
respective physiologic effects on the body, as has been done as follows: 

Altitude * Relative Body % Arterial O2 

Gas Volume Saturation 

Sea level 1.0 96. 

5. 000 ft. 1.2 92. 

10, 000 ft. 1.5 88. 

15, 000 ft. 1.9 80. 



Our first task is to be certain that the patient is not suffering from a 
contagious disease and that he is acceptable as a passenger on an airline in 
accordance with their regulations. 

Airsickness. We next should consider the possibility of the patient's 
becoming airsick and decide whether the resultant nausea and vomiting would 
have any detrimental effect on the primary disease. In this connection, we 
would think of moderately severe cases of valvular heart disease, angina 
pectoris, coronary thrombosis, hypertension, and of peptic ulcer patients 
threatened with perforation. 

Where it is desired to reduce possibility of airsickness to a minimum, 
prophylactic use of one of the recently developed anti -motion -sickness remedies 
is indicated because they are highly effective and have few, if any, side effects. 

Expansion of body gases . Gases normally present in the middle ears, 
sinuses, stomach, and intestines will expand at altitude to the extent shown in 
the above table. Gas in the middle ears and sinuses will cause difficulty with 
ascent only if the orifices of these orgaasL^re blocked, in which case the 
resulting pressure will cause localissed pain which may become quite severe. 
The same applies tp descent except that the pressures will be negative. 

At the higher altitudes, large unsupported hernias may become distended 
and strangulate. Patients with colostomies should be advised that their colos- 
tomy bag will tend to fill rapidly during ascent and that it ought to be emptied 
just before departure time or disposable bags utilized. Patients with appen- 
dicitis or with deeply eroded peptic ulcers or other serious weaknesses of 
the gastrointestinal wall may be endangered by expansion of the contained 
gases, especially if the latter are present initially in more than normal 
amounts. Individuals suffering from a pneumothorax should definitely not fly 
since expansion of the trapped gas will force the mediastinum laterally with 
serious consequences. 



Medical News Letter, Vol. 27, No. 8 



39 



Hypoxia . Fortunately, the first portion of the oxygen dissociation 
curve is quite flat and it is not until we pass 10,000 ft. altitude that hypoxia 
becomes of much significance in the normal resting person. Few physicians 
appear to realize this fact and as a consequence have been unnecessarily 
restrictive in permitting cardiac and respiratory patients to travel by air. 

Patients with symptom -free and compensated valvular heart disease, 
quiescent angina pectoris, ambulatory coronary thrombosis , hypertension 
with a diastolic pressure of 110 mm. Hg. or less, and chronic anemia, and 
leukemia patients with a hemoglobin of 60% or above, all can fly without 
question. In borderline cases, the patient can be flown if oxygen is used. 
Individuals with more serious involvement of the cardiovascular system 
should, of course, not be permitted to travel as ordinary passengers. 

Persons suffering from pulmonary diseases can usually fly without 
difficulty provided their pulmonary reserve is not reduced to the extent that 
the patient exhibits dyspnea on slight exertion. If dyspnea exists, these pa- 
tients should not fly. Patients in status asthmaticus are not suitable as air 
passengers, but those with mild asthma can travel between attacks. 

Infants less than 10 days old and individuals in an advanced stage of 
general deterioration from old age should normally not fly. Pregnant women 
suffer no adverse effects and can be accepted without question, provided, of 
course, there is reasonable assurance they will arrive at their destination 
before going into labor. 

After eliminating from consideration patients who are not acceptable 
as passengers on any type of public conveyance or who are too ill to be moved 
over long distances by any means, it is apparent that there are relatively few 
ambulatory patients who will be adversely affected by air travel. Identifica- 
tion of those who should not fly is relatively simple if airline flight procedures 
are understood. In questionable cases, the medical director of the airline 
concerned is qualified to provide expert opinion and guidance. (Major General 
Harry G. Armstrong, USAF (MC): Therapeutic Notes, Parke, Davis and 
Company, 63^: 13-16, January 1956) 

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Frequent Discrepancies in Submitting Standard Form s 88 

Discrepancies in submitting the Report of Medical Examination, - 
Standard Form 88, have increased to a point where some are now being 
returned to the examining activity for completion. This requires an unnec- 
essary administrative work load on that activity as well as on the Bureau 
of Medicine and Surgery, not to mention the delay in processing the report. 
Guidance can be obtained by noting the red marks on the returned Bureau- 
approved copy. These red marks may indicate; (1) an omission (red circle); 
(2) that the item reported is not completely within normal limits, or is border- 
line; or (3) that the item may have been previously reported as defective. 



40 



Medical News Letter, Vol. 27, No. 8 



Reviewing officers should study the returned Bureau -approved copies 
for guidance in subsequent submissions as well as ascertaining the Bureau 
action. In many cases, the Bureau's endorsement contains certain stipula- 
tions or requests for further examinations. The cooperation of the reviewing 
officers in this review will improve the reports and eliminate delays due to 
the returning of incomplete forms. 

Standard Forms 88 have been returned recently for combinations of the 
following discrepanceis and omissions: (1) Speech Qualifications for Naval 
Aviation Observers (Radar) and for Air Controlmen; (Z) Flight Time; (3) Mark 
and Scars; (4) Depth Perception ("Passed" is insufficient — must be reported a 
"8/8" et cetera); and (5) Current Refractions. 



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